Mcdowell dentistry

New patients Welcome to our practice. Our primary purpose is to serve you and your family, to provide for your dental health needs in a considerate and caring fashion. For your protection this office has the most modern equipment, the latest techniques, above all, we follow OSHA guidelines in advanced sterilization technology for both staff and patient protection. Consent for Services As a Condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, and any dental services performed without previous financial arrangements, must be paid for in full at time services are preformed. I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination. (Initials)________

Medical and Dental Authorization I have read the information on the health questionnaire and it is accurate to the best of my knowledge. I understand that the dentist to help determine appropriate and helpful dental treatment will use this information provided. If there are any changes in my medical status, I will inform the dentist. (Initials)________ Insurance Authorization If you have dental insurance, we will gladly process your forms. However, we request that you pay your estimated portion when services are rendered. Please remember that our contract for payment is with you and not your insurance carrier. We are happy to bill your insurance as a courtesy to you, when you have provided us with your complete insurance information. We allow 45 days from the date of service for payment from an insurance company. After this period, we ask you to become responsible for payment of all unpaid fees. (Initials)________ Cancelled/Missed AppointmentsWe reserve the right to charge $40.00 for appointments cancelled or missed without 24hrs-advanced notice. (Initials)________

Payment OptionsPayment is due at the time of treatment. We accept cash, check, and all major credit cards. We also have two no interest payment plans, Care Credit and All Care, that allows you to start treatment today and spread payments over time. Applying for Care Credit and All Care only takes a few minutes and there is no fee to apply. Just as a reminder, anytime you apply for any type of medical or dental financing, it will not affect your credit score. Please indicate below the form of payment you will be using, please check one: _____ Cash or Check _____ Major Credit Card _____ Care Credit or All Care (Subject to credit approval) if credit application is declined, another form of payment listed above is required. I HAVE READ THE ABOVE OFFICE POLICIES AND CONDITIONS OF TREATMENT AND AGREE TO THEIR CONTENT. ___________________________________________________Date_________________ Signature of patient, parent or guardian PATIENT INFORMATION
Do we have your permission to email you our news let er YES / NO

Responsible Party

Insurance Information

Additional Information

Dental History
Check if you have had problems with any of the fol owing:
Medical History
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of lonimin, Adipex, Fastin (brand
names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).
Have you had any serious il nesses or operations?
Have you had any of the following: please circle
List medications you are currently taking and the correlating diagnosis:
Authorization and Release
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to
inform my doctor if I, or my minor child, ever have change in health. I certify that I, and/or my dependent(s), have
assign directly to McDowell Dentistry all insurance
benefits, if any, otherwise payable to me for services rendered. I understand that I am financial y responsible for all
charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The
above-named facility may use my health care information to the above-named Insurance Company(ies) and their
agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for
related services. This consent wil end when the current treatment plan is completed or one year from the date signed
Signature of Patient, Parent, Guardian or Personal Representative
* Important Medical Alert *
A connection between Fosamax, and other bisphosphonates, with a serious bone
disease called Osteonecrosis of the jaw (ONJ) has been found.
Bisphosphonates are commonly used in tablet form to prevent and treat osteoporosis in postmenopausal women. They are also used in the treatment of Paget’s disease. Stronger forms given orally or intravenously (IV) are commonly used in the management of advanced cancers including, but not limited to, lung cancer, breast
cancer, prostate cancer, multiple myeloma, and other masatic cancers.
Have you ever taken any of the following bisphosphonates? Y N Alendronate (Fosamax) Y N Raloxifene (Evista) Y N Clodronate (Bonefos, Ostac) Y N Risedronate (Actonel) Y N Etidronate (Didronel) Y N Terparatide (Foreto) Y N Ibandronate (Boniva) Y N Tiludronate (Skelid) Y N Pamidonate (Aredia) Y N Zoledronate (Zometa)
If yes, when? ____________________________________________________________
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Prescribing Doctor: ___________________________________ _________________
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NOTICE OF PRIVACY PRACTICES McDowell Dentistry 14122 McDowell Road Suite 200 Goodyear, Arizona 85388 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our commitment here at McDowell Dentistry is to serve our patients with professionalism and caring, being sure at all times to PROTECT the privacy and security of all Protected Health Information.

During the course of serving your interests, it may be necessary to share information with other Health Care Providers or Business Associates. The following are examples of instances where information may be shared:

• During treatment, we may find it necessary to consult with a dental laboratory.
• For payment purposes, we may use the services of a billing service.
During dental care, we may need to consult with your physician or previous dentist.
• For payment purposes, we need to supply information requested from your dental insurances company. We here at McDowell Dentistry are committed to obeying all Federal, State, and Local laws and regulations regarding Privacy Practices. If any other uses or disclosures than the ones listed above are needed, information will only be released with the written authorization of the individual in question. The individual, as provided by law, may revoke this written authorization at any time.

YOUR DENTAL APPOINTMENT HAS BEEN RESERVED ESPECIALLY FOR YOU. THE OFFICE MANAGER WILL CALL THE DAY BEFORE YOUR SCHEDULED APPOINTMENT TO CONFIRM THE TIME SET FOR YOU. IF YOU NEED TO CANCEL YOUR APPOINTMENT FOR ANY REASON, KINDLY GIVE US 24 HOURS NOTICE, OR A $40.00CANCELLATION FEE WILL BE CHARGED TO YOUR ACCOUNT. THANK YOU FOR HELPING US PROVIDE QUALITY DENTAL CARE, BY RESPECTING THE APPOINTMENT TIME SET FOR YOU. _____________________________________________